1. A nurse in an emergency department is caring for a client who recently experienced partner
violence. The nurse is reviewing the client’s medical record at discharge.
Indicates potential improvement: Client’s reportedpain level of left wrist. Client agrees to an
appointment with a social worker. Client requestshelp developing a safety plan.
Indicates potential worsening: Client claims responsibilityfor the physical altercation. Client
states that the partner will not be violent in the future.
2. A nurse A nurse is caring for a client. Complete the diagram by dragging from the choices below to
specify what condition the client is most likely experiencing.
Potential condition: Schizoid personality disorder
Actions to take: Establish clear and realistic boundariesregarding behavior. Maintain a low
stimuli environment.
Parameters to monitor: Aggressive and violent behavior. Provocative behavior.
3. A nurse is caring for a client who states, “I have been having trouble sleeping for the last several
months.” Which of the following responses should the nurse make?
“You should avoid stressful activities prior to going to sleep.”
4. A nurse is recommending community resources for a client who has a chronic mental illness and
agrees to outpatient treatment. Which of the following outpatient care settings should the nurse
identify as a community resource for the client?
Assertive community treatment (ACT)
5. A nurse is caring for a client who is under observation for suicidal ideatios and has verbalized a
suicide plan. The client demands privacy and to be left alone. Which of the following statements
should the nurse make?
“We are concerned about you and need to keep you safe.”
6. A nurse on an inpatient mental health unit is caring for a client. The nurse is discussing the
assessment findings on day 3 of admission during the 1200 change of shift report.
Indicates potential improvement: Hygiene. Food intake. Rapid change in mood.
Indicates potential worsening: Giving away car. Conditionof skin on right hand.
7. A nurse is reviewing the medical record of a client who has schizophrenia. The nurse is preparing
to administer medications at 0800 on day 4 of admission.
The nurse should clarify the prescription for b as evidenced by the client’s b .
, 8. A nurse is caring for a client who has a depressive disorder. The client states, “I don’t always go to
bed at night, so I get in trouble for falling asleep at work.” Which of the following interventions
should the nurse recommend?
“Keep a sleep diary to promote a consistent sleep schedule.”
9. A nurse working in an outpatient mental health facility is caring for a client who has anxiety and
was discharged from an inpatient mental health facility 1 week ago.
Client appears to be well groomed.
Client states they are sleeping 5 to 6 hr per night, but having an occasional nightmare.
Client engages in thought stopping behavioral therapy and cognitive restructuring.
Client reports taking escitalopram 20 mg daily 2 hr after breakfast.
10. A nurse in a mental health clinic is assessing a client who has borderline personality disorder.
Which of the following findings should the nurse expect?
Intense efforts to avoid abandonment
11. A nurse is caring for a client who is involuntarily admitted for major depressive disorder and
refuses to take a prescribed oral antianxiety medication. Which of the following actions should the
nurse take?
Offer the client the medication at the next scheduled dose time.
12. A nurse is caring who is prescribed massage therapy to treat panic disorder. The client states, “I
can’t stand to be touched by another person.” Which of the following responses should the nurse
make?
“I will tell your provider that you would like a treatment other than massage.”
13. A nurse is reviewing new prescriptions for a client who is experiencing acute manifestations of
alcohol withdrawal. Which of the following medications should the nurse expect the provider to
prescribe for this client?
Chlordiazepoxide
14. A nurse is caring for a client following a physical assault. The client states, “I don’t remember what
happened to me.” The nurse should recognize that the client is using which of the following
defense mechanisms?
Repression
15. A charge nurse is discussing the care of a client who has a substance use disorder with a staff
nurse. Which of the following statements by the staff nurse should the charge nurse identify as
countertransference?
“ The client is just like my brother who finally overcame his habit.”
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